Overactive Bladder Syndrome –

behavioural modifications to pharmacological and surgical treatments

Dr Jos Jayarajan

Urologist – Austin Health, Eastern Health

Warringal Private, Northpark Private, Epworth

Overactive Bladder Definition

URGENCY

+/- URGE

INCONTINENCE

+/- FREQUENCY

(> 8 x daily)

+/- NOCTURIA

(> 1 x night)

How Common is OAB?

Incidence (population based studies): Male: 7- 27%

Female: 9 - 35%

Impact of OAB

• Quality of life• Social isolation (family, partner, friends)

• Sexual health

• Reduced participation in sport

• Sleep disturbance

• Financial

• Health• Mental health (depression)

• Skin integrity

• Falls and fracture

Approach to Treatment

• Exclude pathology• Urinary tract infection

• Red flags (haematuria, dysuria, elevated post void residual)

• Lifestyle and Behavioural modification

• Optimise associated medical conditions

• Pharmacotherapy

Investigations

• MSU

• Exclude UTI

• Exclude microhaematuria

• Renal tract ultrasound (PVR)

• Bladder diary

PATIENTS with RED FLAG sxSpecial Tests / Referral

• Haematuria

• Elevated PVR / obstructive voiding

• Neurological symptoms

• Prior history of pelvic pathology

• Radiation

• Continence or prolapse surgery

Cystoscopy

Urodynamics

CT / MRI

Red flags: Haematuria

Red flags: Previous Mesh Surgery

Behavioural Therapy

• Patient education

• Bladder retraining and Pelvic Floor Muscle Therapy

• Timed or deferred voiding

• Urge Suppression

• Biofeedback

Behavioural Therapy

• Bladder retraining and Pelvic Floor Muscle Therapy

• Level 1 evidence

• Improvement in QoL, urinary frequency and incontinence episodes

• Some studies show equivalence to medical therapy

Pharmacotherapy in combination with Behavioural Therapy is

superior to either alone

Lifestyle Modification

• Fluid and caffeine management• Level 1 evidence

• Weight management

• BMI > 30 increases OAB symptoms

• Weight loss may improve OAB symptoms in

women by upto 47% (Subak et al)

• Bowel management

• Optimise associated medical conditions

• Diabetes, Obstructive Sleep Apnoea, CHF

Normal Bladder Storage

1. Arnold J, et al. Aust Fam Phys 2012;41(11):878 -83.

1 1

Inhibitory sympathetic

and somatic pathways

Suppression of

excitatory

parasympathetic

outflow

First line pharmacotherapy

Anticholinergics

• Target muscarinic receptors on detrusor muscle

• Action on muscarinic receptors at other sites causes unwanted effects

• Dry mouth

• Constipation

• Blurred vision

• GOR

• Precaution• Untreated narrow angle glaucoma

• GIT motility disorders

• Urinary retention

• Elderly

Anticholinergics

OXYBUTYNIN

• Immediate release and non-selective

• Short half-life

• Dosing: 2.5 - 5mg tds

• PBS

• Side effects• Dry mouth (71%)

• Constipation (17%)

• Somnolence (14%)

• Cognition

Anticholinergics

OXYBUTYNIN PATCH

• Controlled release

• Dosing: Twice weekly application

• Avoids first pass hepatic metabolism

• Side effects• Patch site pruritis

• Dry mouth, constipation

Anticholinergics

SOLIFENACIN

• M3 receptor selective

• Long half-life

• Dosing: 5-10mg daily *

• Side effects (10mg > 5mg)• Dry mouth

• Contipation

• cognitive

Anticholinergics

DARIFENACIN

• M3 receptor selective

• Long half-life

• Dosing: 7.5 - 15mg daily

• Similar efficacy to Solifenacin

• Solifenacin superior QOL / tolerance

Mirabegron

• B3 adrenergic agonist

• Dosing: 25 – 50 mg daily

• Avoids anticholinergic side

effects

• No change to residual volume

• Avoid in uncontrolled

hypertension

Topical Oestrogen

• Some evidence of improving OAB symptoms in post-menopausal women

* Not systemic HRT

Other medications

• Tricyclic antidepressant

• Not FDA approved for OAB

• Reduces bladder contraction

• Useful for patients with combined storage and painful bladder

conditions

> 30% total urine output

Nocturia

NOCDURNADesmopressin

• Sublingual wafer

• Dosing• Women: 25mcg

• Men: 50mcg

• 1 hour before bed

• Limit fluid 1 hour prior to admin, and 8 hrs post

• Monitor serum Na +

Overactive Bladder in Men

Exclude Bladder Outlet Obstruction

• > 50% have BPH related obstruction

• High PVR / reduction in flow

• Consider concurrent use of BPH therapy

and OAB medication

Urodynamics In Male OAB

Combination alpha blocker and anticholinergic

• Combination therapy tamsulosin (0.4mg) and solifenacin(9mg)

• No stat sign increase in retention

• Improved storage symptoms and QoL

OAB: Failure of Medical Management

….What next?

Urodynamics

BOTOX

PBS approval for

1. Idiopathic OAB *

2. Neuropathic OAB *

Administration by a Botox registered urologist or

urogynae

Botulinum toxin-A PBS reimbursement criteria1

Clinical criteria: Urinary incontinence due to idiopathic OAB

AND

• Must be inadequately controlled by therapy involving at least two alternative anticholinergic therapies

• Must experience at least 14 episodes of urinary incontinence per week prior to commencement of treatment with botulinum toxin-A

• Must be willing and able to self-catheterise

• Must not continue if the patient does not achieve a 50% or greater reduction from baseline in urinary incontinence episodes 6–12 weeks after the first treatment

Patient criteria: Must be 18 years or older.

Treatment criteria: Must be treated by a urologist; OR urogynaecologist.

1. Botulinum toxin-A. PBS schedule. Available from http://www.pbs.gov.au/medicine/item/6103F. Accessed September 2015.

Botox: Long-term Efficacy

• Durable response at 3.5 years

• Median duration 7.9 months

• Main complication UTI

• Retention rate 4% after first injection, 0.6% – 1.7% with repeat rx

78yoM

• Previous TURP

• Cystoscopy – normal urethra, wide open fossa

• Urinary symptoms

• Poor flow

• Urgency / frequency / large volume urge incontinence

Sacral Neuromodulation

INDICATIONS

• Detrusor overactivity

• Non-obstructive Urinary Retention

• Faecal incontinence

Sacral Neuromodulation

• Modifies voiding reflex using direct electrical stimulation of S3

afferent nerve

• Indications: refractory OAB, non-obstructive urinary retention

• Contraindications: need for spinal MRI

• 2 stage procedure

• Average 75% response rate

Stage 1

• S3 lead placement under fluoroscopy in theatre

• Testing phase 2-3 weeks

Stage 2

• Second Stage if >50% reduction in symptoms

• Otherwise removal of lead

• 3-5 year battery life

Conclusion – Approach to OAB

1. Exclude other conditions that can mimic OAB

2. Multi-disciplinary and holistic Patient specific treatments

3. Caution in the elderly

• Falls risk / Side effects of medication (anticholinergics)

4. Men with OAB

• Treat the prostate when required

5. Third line treatments (Botox / SNS) – highly effective